RESTORATIVE ENVIRONMENT: CAREGIVERS EVALUATION ON HOSPITALIZSED CHILDRENS PREFERENCE TOWARDS GARDEN VERSUS WARD IN MALAYSIAN HOSPITALS

Ismail Said Mohd Sarofil Abu Bakar Department of Landscape Architecture, Faculty of Built Environment Universiti Teknologi Malaysia, 81310, Sekudai, Johor, Malaysia b-ismail@utm.my
Proceedings of the 6 International Symposium for Environment-Behavior Studies EBRA, Tianjin, China, Oct. 22-25, 2004
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Abstract
Hospitalization often erodes the feelings of toddlers and young children that cause regressive behaviors and stress resulting to reduced cognitive performance, helplessness, restlessness, crying, anxiety, and elevated blood pressure. Having the children experiencing a garden setting, either in passive or active mode, can arouse their senses that nurture their inductive and deductive, motor-impulses development and reflective thinking capabilities and thus reduce the stress that would foster their recovery. This study investigates the impact of garden on the psychological well-being of pediatric patients, toddlers and young children aged 2 to 12 years, by determining their preferences toward the domains (properties and attributes) of a garden and ward in two Malaysian hospitals. It uses two sets of administered questionnaires evaluated by the caregivers, Set A for mothers as surrogate respondents, and Set B for ward nurses. Univariate analysis of the data found that 94% of the pediatric patients (n=360) preferred the garden than the ward. Bivariate analysis on the mothers evaluation data found that the mean preference scores of the garden are greater than the ward in all domains except one. The domains are refreshing smell, fresh air, full with light, cheerful environment, pleasant sound, scenic view, open space, free to play, not confined, home feeling, and place for variety of activities. Moreover, 71% to 93% of the nurses viewed that the garden affords the patients to (1) play freely and safely either alone or with peers, (2) escape from the confined ward environment into an open space where they can observe animals, and (3) gain control on their movement. As a result the patients feel cheerful and agile to the garden setting suggesting theirs cognitive functioning are restored.

**** Keywords: pediatric patients, hospitalization, garden, restoration, cognitive functioning

Introduction: Hospitalization and Garden Restorative Effects Research in nursing, healthcare management, health psychology, pediatric psychology and child psychiatry found that most children view hospitalization as a threat, and thus they experience ill effects from being hospitalized (Cooper Marcus and Barnes, 1999; Hart, 1995; Johnson, 1994; La Greca and Bearman, 2000; Lindheim et al. 1972; Rubin et al. 1998; Zahr, 1998). Some of the ill effects are caused by regulated medication, confined space, loss of habitual control due to the clinical treatment, alien smells, and staying with strangers, and way-finding difficulties in complex and unfamiliar hospital settings (Cooper-Marcus, 1999; La Greca and Varni, 1993; La Greca and Bearman, 1999; Lau, 2002; Lindheim et al., 1973; Moore, 1999). Thus the children see the hospital environment as an unfamiliar and strange setting with conditions that inflicts pain and segregation from their families and favorite places. This is the environment which they have no control on their bodies and behaviors (Lindheim et al., 1972; La Greca and Bearman, 2000). Such unfamiliar and strange settings are common because design of most late twentieth century hospital concentrate on creating healthcare buildings that would reduce infection risks and serve as functionally efficient settings for new medical technology (Ulrich, 2002). The design left the outdoor space such as garden as peripheral landscape which not intended for the healing process of the patients (Copper Marcus & Barnes, 1999). As a result, hospitalization often erodes the feelings of toddlers and young children causing stress (Lau, 2002) resulting to reduced cognitive performance, helplessness, restlessness, crying, anxiety, and elevated blood pressure (Lindheim et al., 1972; Olds, 1987; Oremland and Oremland, 1973; Korpela, 2001; Zahr, 1998). Eventually, the patients react regressively such as excessive fears, anxiety, increased clinging to and dependence on parents, loss of bowel and bladder, intensified thumbsucking, or low self-esteem (Johnson, 1994; Lau, 2002; Lindheim et al., 1972).

Creating garden as playspace in the hospital environment generates sense of familiarization to the children (Olds, 1987) toward their home and school environments (e.g. Proshanky & Fabian, 1987) and thus would calm them (Ulrich, 2002). The children can experience many similar landscape features such as vegetation and animals, landscape factors including rain, sunlight and shadow, temperature and wind, and man-made features particularly play equipment and buildings. Vegetation, animals and microclimatic factors are ubiquitous natural elements that children have experienced in their homes and schools before being admitted to the hospital. Natural elements stimulate their perceptual functioning because they perceive them as (1) endless

diversity, (2) dynamic elements, and (3) elements not made by man (Prescott, 1987). Vegetation and animals in a garden environment come in a variety of shapes, colors and textures. Viewing the garden or playing in it nourishes the children feelings because nature provide a balance of multi-sensory stimulation as opposed to the overload or deprivation found in the built environment such as hospital (Vernolia, 1994).

In contrast to the confined ward environment, the garden allows pediatric patients to move freely. Motion, cycle and scale are three factors that nourish the children intellectual development (Vernolia, 1994). Anita Olds (1989) posits motion permits a child to locate himself freely in space, assume body postures, create his own boundaries, have access to diverse territories, manifest power, and explore his abilities. Apart from the vegetations, animals and microclimatic factors, the children attentions are also on the play equipment (Stoecklin & White, 1998). This is because the garden space, its equipment and other accessories (e.g. pavilion) afford the children a variety of locomotion such as walk, run, hop, jump, roll, ride, sit, hide, dig, mould, pull, pick, bend, grasp, scratch, throw, climb, crawl, swing, slide, and look-out (Kytta, 2003; Heft, 1999). Allowing the patients to perceive and to play with the garden contents is a dynamic experience in an ecological setting (Kytta, 2003). Playing and moving in the garden space from an equipment or a tree to another develop sensorimotor skills (Hartle & Johnson, 1993); an essential step in children development. Consequently, the locomotion shifts the mood of the patients from regressive to progressive ones (Olds, 1989). It affects the cognitive and affective domains of the children behavior (Gallahue, 1993). Hartig and Staats (2003) posit that shifting in mood is a restorative effect because it renews diminished functional and perceptual capabilities of the patients.

Another progressive development that patientscan attain by playing in the garden is socialization. Through play the patients communicate and socialize with their peers in various activities including sharing, turn-taking and resolving conflicts (Hartle & Johnson, 1993). They feel more comfortable and secure playing in a group because one would assimilate and accommodate the behaviors of others (McDevitt & Ormrod, 2002). In addition, they would perceive the garden as a comfortable playspace when the garden provides moderate and varied levels of stimulation for their senses (Olds, 1989). This is achieved when they play in rhythmic patterns of movement that combine predictable sameness with moderate diversity (Olds, 1989). Proper layout and appropriate composition of the garden contents that help maintain optimal levels of responsivity and alertness. Thus having a garden beside the pediatric ward allows the patients to engage with

the natural and man-made features that trigger their senses and ultimately gains psychological and physiological harmony.

Playing in the garden allows the patients to have own control on their performances. Thus they are free to play on features in their own time according to their own decisions. Therefore, they are able to have privacy, to make predictions, and to appropriately orient their bodies in the garden space (Olds, 1989). Consequently, they can improve their performance in tasks including physical play and socialization as well as cooperation toward medical treatments (Ismail et al., 2002). This is a psychophysiological change that Hartig and Staats (2003) recognize it as restorative effect.

This is an empirical, experimental study investigating the restorative impact of garden on the pediatric patient psychological well-being. It utilizes perception of the patients as the unit of analysis. It determines the differences of patients perceptual preferences between the garden and the ward in two Malaysian hospitals. The objective of the study is to proof that patients participating in a garden renew their diminished functional resources and capabilities through play and socialization.

Garden as Playground Two gardens were designed and constructed beside the pediatric wards of Batu Pahat Hospital (BPH) and Segamat Hospital (SH). The first author designed the gardens and supervised their constructions until they were completed in February 2002. Both hospitals are 314-bed capacity and are classified as acute-care type built in similar layout and building forms. Each has two pediatric wards. One of the wards is facing the garden and equipped with 24 beds. Half of the beds are facing the garden through louvered glass windows allowing 12 to 14 patients to view the garden directly from their beds. However, all patients have equal opportunities to go to the garden through two exists: two ward doors that open right into the garden and a playrooms door that open into a patio. The patio is a transition space from the playroom before entering into the garden. It is equipped with a mural on the wards wall, two rattan bucket swings, and a rubbermat floor that serve the patients and their caregivers to rest outside the ward especially in mid afternoon or when it rains. This is starting space for the patients to feel being away from the indoor environment, thus their mind can engage with the variety of garden features and thus promote exploration (Herzog et al., 1997).

There are four spatial zones for playing and resting in BPHs garden and seven zones in SHs garden. The zones include multipurpose lawn areas, play structure areas, sand play area, gardening area, and resting areas with timber pavilions. Plants and garden structures including play equipment define the spatial zoning of the gardens. The play equipment are swing and timber ladder set, balancing bar, treasure chests, overturned urn, triangular rope play, hopping urns, planting boxes, spring-riders and slide. Since BPHs garden is twice smaller than SHs garden it is equipped with only the first five equipment. Apart from the equipment, the garden is equipped with two timber pavilions for resting, three timber benches for seating, two bird feeders and several wind chimes.

Plant selection is based on the effect of stimulation to children senses including (i) foliage shrubs as background for colourful shrubs, (ii) fragrance and bright flowering shrubs for olfactory stimulation and as accent vegetative features, (iii) lawn as flat, soft textural surface for tactile recuperative effect, (iv) matured trees and tall palms as features to provide shade or indicate boundary and landmark, (v) small fruit trees such as banana and hog plums for edible fruits, and (vi) climbers with large flowers laden with nectar to attract insects and birds. Furthermore, common house garden species such as alphinias, bananas, gingers, jasmines, periwinkles, and hog plums are selected to give the feeling or impression of a home-like environment to the patients.

In child-play perspective, the pediatric ward gardens are playgrounds equipped with play equipment, accessories, a variety of vegetations and animals. One of the gardens is shown in Figure 1.0. As playground, they afford three types of play including sensorimotor play, pretend play, and game with rule play. Therefore, the patients have the control to play alone or with their peers in a warm (270 to 330C) and humid tropical climate throughout the year. As outdoor space, they allow the patients to engage and interact with the living and non-living features and microclimatic factors. Therefore, they afford the ill children to renew their cognitive, social and physical functioning (Olds, 1989; Relf, 1998).

Figure 1.0: Site plan of pediatric ward garden at Batu Pahat Hospital

Data Collection and Analysis Patient perception to the garden and ward was gathered from two sets of questionnaires, from the mothers (set A; n=360) and the nurses (set B; n=42). The patients were toddlers and young children, 2 to 12 years old. Both respondents were caregivers in the ward and their views on the patients responses and behaviors were considered as reliable (Holmbeck et al., 2002). In set A, the mothers evaluated the perceptual responses of their children on 12 domains of the garden and the ward. The evaluation was done after the patients have experienced the garden for at least a day. The domains are the properties or attributes of the settings. They include refreshing smell, fresh air, full with light, cheerful environment, pleasant sound, scenic view, open space, free to play, not crowded, home feeling, not confined and various activities. The evaluation was done using 5-point rating scale on how much the children responded to properties or attributes of the

garden and the ward afford the domains. A negative response was scored 1; a positive response was scored 5.

In set B, 42 nurses evaluated the responses of the patients to the spatial qualities of the garden. The qualities were: (a) place where children can feel secure to play, (b) place for children to play and wander safely, (c) place for children to escape from the ward environment, (d) place to encourage recuperation from emotional disturbances, (e) place to encourage children to be more cheerful and agile, (f) place to help children to be more independent, (g) place for observing birds and insects, and (h) place to be with family and friends. This evaluation was done after the garden was opened to the patients for more than two months and they were administered by the nurses. This period was ample for the nurses to assess the impact of the garden to the patients since the patient average length of stays were short, 3.86 days for BPH and 3.21 days for SH (Ismail et al., 2002). The objectives of the evaluation were to measure the impacts of the garden in generating positive feelings in playing and socializing, in encouraging psychological well-being, in having their sense of control, and in exposing them to nature. Similar to the mothers evaluation, 5-point rating scale was applied in which score 1 meant negative that was strongly not successful and score 5 meant positive that was strongly successful. Later the ratings strongly not successful, not successful, and somewhat not successful were considered as failure which meant the garden failed to generate positive feelings to the patients. On the other hand, ratings successful and strongly successful were classified as successful suggesting the garden affecting the patients feelings positively.

Results The mothers evaluation data identified 94% of patients (n=360) preferred to go to the garden than staying in the ward. This is because the garden activities are in much resemblance with those at their homes or schools. Perception of their children on the domains of the garden and ward were analyzed using a standard paired sample t-test to determine difference in mean score. Table 1.0 shows the results of the score on the domains (properties and attributes) of the garden and ward.

Table 1.0: Patient perception toward the domains of garden and ward. Numbers in parentheses are the standard deviations. Domains: Properties Mean & Attributes Refreshing smell Score Mean Score Number of Ward 3.91 (0.90) 4.08 (0.71) 4.24 (0.47) 4.04 (0.83) 3.75 (1.03) 4.15 (0.62) 4.16 (0.67) 4.07 (0.77) 4.25 (0.59) 3.93 (0.90) 4.17 (0.62) 4.14 (0.68) 351 0.000 349 0.001 347 0.000 350 0.825 350 0.000 352 0.000 352 0.000 349 0.000 351 0.000 353 0.000 350 0.000 Respondents 350 of pvalue 0.000 Garden better Garden better Garden better Garden better Garden better Garden better Garden better Garden better No difference Garden better Garden better Garden better is is is is is is is is is is is Conclusion

of Garden 4.23 (0.68)

Fresh Air

4.35 (0.52)

Full with light

4.37 (0.48)

Cheerful environment Pleasant sound

4.34 (0.59) 4.07 (0.88)

Scenic view

4.34 (0.56)

Open space

4.34 (0.54)

Free to Play

4.33 (0.58)

Not Crowded

4.26 (0.67)

Home Feeling

4.18 (0.81)

Not Confined

4.28 (0.68)

Various activities

4.32 (0.58)

As can be seen from Table 1.0, 11 out of 12 domains having p<0.05 indicating the patients are responding differently to the properties or attributes of the garden from the ward. The mean scores of the gardens domians are greater than the mean scores of the wards ones. This result suggests the patient preference towards the properties or attributes of the garden is better than the ward. Therefore, the patients perceived the garden having more or better properties or attributes than the ward in the aspects of refreshing smell, fresh air, full with light, cheerful environment, pleasant sound, scenic view, open space, free to play, not confined, home feeling, and place for variety of activities. However, the patients feel there is no difference bewteen the crowdness of the garden and the ward.

The evaluation of the nurses on patients responses to the garden is shown in Table 2.0.

Table 2.0: Nurse (n=42) evaluation on spatial qualities of the garden for the patients What the garden can offer Failure Success Percentage of success Security for sick children. Place for sick children to play and wander safely Help sick children to be more independent Observing birds and insects Encourage recuperation from emotional disturbances Encourage ill children to be more cheerful and agile Place for ill children to escape from the ward environment Place to be with family and friends 24 12 10 9 6 5 4 3 18 30 32 33 35 37 38 39 43 71 76 79 85 88 90 93

The results show that 90% to 93% of the nurses considered the garden as a successful place for the patients to escape from the confined ward environment to play and be with their families and peers. And 88% of the nurses perceived that escaping from the ward and playing in the garden allows the patients to be cheerful and active. Moreover, 71% of them thought that the patients move and wander freely and safely within the childrens own controls. And 79% of them perceived the patients were cheerful not only playing with the play equipment but also happy observing the animals such as birds and insects. As a result, giving the opportunity to experience

the garden, 85% of the nurses believed that garden was successful in encouraging the patient to recuperate from emotional disturbances.

Discussion Ninety-four percent of the patients preferred the garden than the ward suggest the properties and attributes of the garden afford positive feelings to them. The affordances recognized by the patients are the physical properties such as open space and sensual attributes such as fresh air, refreshing smell, full with light, pleasant sound and scenic view. Interacting with the garden contents stimulated their senses and thus evoked (Wachs, 1989) or nourished their feelings in varied ways (Vernolia, 1994). Air and light are ubiquitous elements of nature that the patients are familiarized with them in their homes and schools. The patients feel that the sense of home feeling in the garden is greater than in the ward; mean score for garden 4.18 versus 3.93 for the ward. Sense of familiarization helps the patients to get acquainted with the environment and thus feel positive to it (Olds, 1989). Therefore, experiencing the garden helps the patients to recall the memories of their familiar surroundings and the experiences are restorative (Chawla, 1992).

In ecological perceptual psychology, the garden is an ecosystem affording the children space to move through play (Kytta, 2003). The patients recognized it as open space for them play freely while experiencing with fresh air, sunlight, beautiful scenery and refreshing smell. Seventy-one percent of nurses perceived the garden as a successful space for the patient to play freely and safely. Through play the patients able manifest their power; 88% of the nurses perceived the garden encourages the children to become agile and cheerful. Moreover, 76% of the nurses viewed that the patients behaved more independent. This means the garden supports the patients to play and move within their own controls. Thus they able to participate in various activities such walk, run, hop, jump, roll, ride, sit, hide, pick, grasp, scratch, throw, climb, crawl, swing, slide, and look-out using the garden features and space. Therefore, garden features stimulate and support manual dexterity skills which are essential in cognitive and physical functioning of child development (Kellert, 2002). Positive perception is thus generated because play and movement are the very center of young childrens lives (Gallahue, 1993). Having sense of control allows the patients to make predictions (Olds, 1989) that hospitalized children get little or none from the ward (La Greca and Bearman, 2000; Lindheim et al., 1972). Thus the patients shift their moods, for example, from less cheerful in the ward to more cheerful in the garden environment.

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According to Hartig and Staats (2003) such shift is a restorative impact because it renews diminished functional and perceptual capabilities of the patients.

Moreover, 79% of the nurses perceived that the garden is a place for the patients to interact with animals such as birds and insects. Such dynamic interaction improves responsivity and fascination to the children (Myers & Saunders, 2002). And fascination is one of the factors of restoration process, leading to patients psychological well-being (Korpela, 2001).

In addition, through play the patients able to socialize with family and peers; 93% of the nurses viewed the garden as a successful in contributing this phenomenon. This behavior contributes to the cognitive development of the children because they able to negotiate, to compromise and to reduce conflicts through social play (Hartle & Johnson, 1993). Transaction with peers allows the children to assimilate their peers actions, for example, a toddler learns from older sibling how to ride on the springrider. Once he attains his control on the equipment he can create additional action; an accommodation process. Both assimilation and accommodation are essential stages in children cognitive, social and physical development (McDevitt & Ormrod, 2002).

Studies by Whitehouse et al. (2001) and Irvine & Warber (2003) found that there are lack of explicit assessments of how garden might influence indices of pediatric patients healthcare preference and satisfaction, such as assessments of spatial quality, effects of vegetation and animals, effects of garden equipment and accessories, and effects of microclimatic factors. This exploratory research adds to the understanding of the impact of garden and nature in fostering the rehabilitating process of pediatric patients in hospital environment. Although the findings of this study are far from conclusive it helps to fill a small portion of the gap on the significance of garden in healthcare environment for hospitalized children.

This finding is in accord with studies by Whitehouse et al. (2001), Copper Marcus (2002), Korpela et al. (2002) that active participation through play in the garden generate initial affective reaction (cf. Ulrich, 1999) that enhance the restoration of their psychological well-being (Hartig & Staats, 2003).

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